Joey Wahler (Host): It's a big part of our health later in life, so we're discussing geriatric dentistry. Our guest is Dr. Annie Kwam. She's a dentist for International Community Health Services. This is Together We Rise from International Community Health Services. Thanks for joining us. I'm Joey Wahler. Hi there, Dr. Kwan. Welcome.

Annie Kwan, DDS: Hello. Thank you.

Host: Great to have you aboard. So first, what age group actually encompasses geriatric dentistry and why is dental care for older adults so important?

Annie Kwan, DDS: We usually classify geriatric dentistry as 65 and above. We have an increased risk for oral disease as we age. Just strictly for manual dexterity, abilities to keep things as they are. There's a number of things that can go into why dental care is so much more important as a older, adult. So we like to make sure that we're keeping on top of things, preventative medicine and everything like that.

Host: I'm curious, as we get older, we tend to have more health issues, right? Does that sometimes prevent older folks from paying enough attention to their teeth? Maybe some other health conditions get in the way of being as diligent?

Annie Kwan, DDS: Yes, 100%. Whenever you age, you tend to have more physical limitations, you might have access to care issues, like transportation is a big one, and there are just increased numbers of systemic issues, medical issues that can contribute to a decrease in dental abilities, and to keep your, um, mouth kind of healthier.

Host: What are the most common oral health conditions that affect older patients?

Annie Kwan, DDS: One of the big things is dry mouth. As you age, there are usually increased number of medications that you need to take, anywhere from four and above medications. They usually do tend to see a trend of dry mouth. The other thing is with root caries. So typically for younger patients, they are more concerned with cavities on the outside of the tooth, on the enamel surface.

But as we age, we do have gum recession. When gums recede, it does uncover a bit more of the tooth and underneath the root structure is a lot softer and more susceptible to decay. You also do have just the ability to move your tongue and move your cheeks. With the motion of your cheeks and your tongue; it does tend to have like a washing cleaning effect. So with the decrease of salivary flow, and also the decrease in motility of your tongue and your cheek, it just doesn't allow for as much just natural cleansing as you would normally get.

Host: Interesting. Let me ask you a little bit more about a few of those things you just mentioned. Dry mouth. Why is that more of an issue in older people?

Annie Kwan, DDS: With increased medications, medications can sometimes cause a decrease in salivary flow, and also just as we age things kind of tend to break down a little bit so your salivary glands are not as active as they could be.

Host: Anything we can do about that to prevent it, or maybe have it not be as much of a problem?

Annie Kwan, DDS: Yes, definitely sipping on water throughout the day, just making it a point to have liquids close by. Usually water is going to be your best bet. There are also, salivary supplements that you can take, like XyliMelts, things that you can just keep in your mouth. Once your mouth detects that there is something in your mouth, it tends to increase the salivary flow, because it's thinking that you're eating. So you can use sugar free candies, you have sugar free gums.

 And there are in really severe cases, prescription medications that can be prescribed to increase salivary flow. That's more of like a line of defense if there's just very, very dry mouth.

Host: And then Doctor, you mentioned gum issues being more prevalent as we age. What are some of the things we can do to strengthen our gums? I would imagine diet is part of that. Yes?

Annie Kwan, DDS: The gum issue more would be keeping your teeth clean. When you have plaque buildup, if you have a biofilm on your teeth, it is a foreign substance, if you want to think of it that way. It's just like if you got a splinter on your finger, the area around gets really inflamed, it gets irritated.

And once gum tissues get irritated it will actually kind of act as a defense mechanism and it will start receding.

Host: And you led me beautifully there into my next question, because we hear that term, receding gum line. What does that mean actually? And what's causing that?

Annie Kwan, DDS: When you have recession on your gums there's a number of factors that can cause recession. For younger people it's tends to be if they've had any kind of ortho treatment, so braces. Sometimes just the movement of teeth through bone will cause gum recession. But as we age, some of the recession can be due to underlying gum disease. When you don't have regular routine cleanings, you do get calculus buildup.

So it's essentially plaque that's on your teeth. It getsmineralized by the minerals in your saliva, and it sticks onto your teeth. And once it gets onto your teeth, your gums will be really irritated by them. And once they get irritated, they kind of start retreating from the irritant.

 And unfortunately, it's a cyclical effect. So it gets irritated, you and you uncover more of your root structure, you get more buildup, and eventually what happens is you get calculus buildup underneath your gums, and then your bone actually will follow suit. So the bone does not like foreign objects close to it. So when the bone recedes, the gum will also recede.

Host: That's a great explanation. I can actually picture all that happening as you describe it. And so if you do happen to contract gum disease, how is that typically treated?

Annie Kwan, DDS: So we will diagnose gum disease by doing something called periodontal charting. What that is, it's a little measuring probe that we use. It's not the most comfortable thing, but we do use it as a diagnostic tool. So it's whenever your dentist is saying just a whole bunch of numbers like 3-2-3, 4-3-4, something like that, and what we're doing is we're measuring from the outside of your gums until the probe will meet some resistance.

 So that tells us how much bone is around the tooth. So once you have those measurements, if they are deeper than a 4mm or 5mm depth, you are in the realm of gum disease.

Host: So basically you're supposed to have a certain amount of buffer there, so to speak?

Annie Kwan, DDS: Yes, that's correct. So, anywhere three millimeters and shallower, you're able to floss, brush, and keep it clean, and then with every six months checkup and cleaning, it should tend to stay in that realm. However, if you start getting deeper pockets, your daily oral hygiene routine just isn't sufficient.

Host: And so what's done about that?

Annie Kwan, DDS: The treatment for gum disease would be something called a scaling and a root planing. We usually will call it, it's a deep cleaning. What that entails is because cleaning underneath your gums can cause a certain amount of discomfort, we will anesthetize or numb the area so that it's comfortable for the patient, and we will take our ultrasonic cleaner and also hand scalers and remove the buildup that's underneath the gumline.

Host: The ultrasonic cleaner, the heavy artillery, right?

Annie Kwan, DDS: Oh yeah.

That's everyone's favorite.

Host: That's an overly thorough cleaning that I would imagine tends to be a bit more painful for certain people when they have that done than a typical cleaning or no?

Annie Kwan, DDS: It can be uncomfortable, if you elect not to be anesthetized. So if you're not numb, definitely it can be a lot more uncomfortable than just a straightforward cleaning. We are having to manipulate under your gums. So, with your, you know, it's just like your skin, if you scratched along your skin, you would also have just a little bit more sensation there.

So, whenever we do our scaling and root planings, we do typically anesthetize. We do numb. So once you're numb, we can clean your teeth and you should not feel anything at all. There may be some slight pressure sensation, but that's about it.

Host: Good to know. A few other things. First, when we talk about typical oral hygiene products that are used at all ages, toothbrushes, toothpaste, floss, mouthwash, et cetera, any particular recommendations from you for the older population?

Annie Kwan, DDS: It is dependent on each patient. It depends on what their risks are. If they're high cavity risk, then we do recommend, a fluoride toothpaste, that is prescription. if they are getting a lot of root decay, one of the things that they can do on a daily basis is brush with a high sodium fluoride content toothpaste.

Unfortunately, it's just not available for purchase. You do need to get a prescription for that. But what that does is it just allows an excess amount of fluoride in your toothpaste to kind of get around your teeth. And fluoride does neutralize acidity and it also helps to remineralize teeth a little bit better.

For the cavity prone patient, that's what we would recommend. If you are, more periodontal disease or gum disease risk, then there are a number of different hygiene products that you can use, more so than just your, manual toothbrush and manual floss, just normal floss. When it comes to toothbrushes, we do tend to recommend electronic toothbrushes.

 They make the motion for you, so it kind of takes the guesswork out of proper brushing techniques. But if it is something that you kind of want to review with your dentist for sure, we will always review that with you, or even our hygienists will definitely go over the most optimal technique for brushing.

And as far as flossing goes, flossing requires a lot of manual dexterity. And as we age, arthritis, osteoarthritis, some people have rheumatoid arthritis, or just even just mobility of your fingers decreases. So for that kind of population, if they are having issues with flossing, just with a string floss, there are flossers that you can use that even have very long handles.

So they have a long handle and they have a flosser at the very end, which allows for the user just to hold on to a handle instead of having to manipulate anything in their mouth. There's also different flosses that if you do have gum recession, you tend to have more spacing between your teeth. There are floss types that will expand when they touch saliva.

So it looks like a string just coming out of the package, but once you get it in between your teeth and it touches saliva or water, it will become a little puffy, around the floss that's between the teeth. And that does allow for a little bit more thorough of a cleansing.

 You can invest in a water flosser. So there's a number of companies now that make water flossers. If dexterity is really an issue, the water flossers do have larger handles and so they're easier to grasp, they're easier to move around.

Host: Very good advice indeed. A few other things though, before we let you go, chewing gum. The dentist, perhaps our parents as well, warn us from a young age, not good for the teeth. How about for older patients?

Annie Kwan, DDS: Chewing gum is it depends. So, people can definitely benefit from chewing gum. There are a number of gums that are now, well one you want to stick with, only sugar free chewing gum, and this is kind of across the board. You don't really want to have any kind of chewing gum with sugars in them, just because it's just refreshing the sugars in your mouth, which can cause a higher cavity risk.

 But there are gums out there now that have a sugar substitute that's called xylitol. And there have been some studies about Xylitol decreasing your risk for cavities. One of the caveats of that is when you look at the ingredients, Xylitol needs to be the first ingredient of the gum.

So that it has higher concentration of Xylitol. You need a certain amount in order for it to be effective. With any kind of chewing gum, I do recommend just chewing it after meals for maybe a period of 20 to 30 minutes. And then the effects of the gum are pretty much null and void at that point, you can spit it out. You do want to avoid chewing the whole day. That can sometimes lead to some jaw issues, some bite issues. So, chewing gum, it depends on what you choose. making a choice to chew like Xylitol, chewing gum is usually a pretty good deal after you eat for 20 or 30 minutes.

Joey Wahler (Host): What would you say the goal is for you and yours on the dental team when treating aging patients? Is there one thing in particular that you think is a common theme?

Annie Kwan, DDS: The theme with treating older patients, is there's a lot of flexibility involved. Every patient is going to be quite different in their needs and their abilities. There are some patients who can still tolerate dental treatment really well. And for those patients, you can treatment plan in a way that will reduce oral disease, so cavities or periodontal disease.

There are some patients that have very difficult time tolerating dental treatment as far as doing fillings and cleanings go. And for those kinds of patients, you do need to pivot in a sense that what they're able to tolerate is going to dictate what you can do. There are some cases where it's less than ideal treatment, but it is the ideal treatment for that patient in particular.

Host: And in summary here, Doctor, it seems the old motto, an ounce of prevention is worth a pound of cure applies here specifically to geriatric dentistry. Yes? Try to ward off those problems earlier and you'll have better fortune later with your teeth, right?

Annie Kwan, DDS: That's completely correct. We as dentists try to push the message of preventative. Everything is preventative. Even in medicine, everything is preventative. When you start at an early age and you work into those habits, a lot of times you set yourself up for success later on. So, with parents, new parents, even patients who are about to have a child, we will talk to them a little bit about preventative oral care.

 So getting that message out early, very, very early on is key. We recommend patients, as young as six months old, or even when they just get their first tooth, you know, whether it be three months or a year, to go ahead and start coming in to the dentist. One, just to have just a wellness check, and then two also to have them get used to what it means for someone to, for a stranger, essentially, to be in your mouth to be looking around and touching around.

And unfortunately, the message of prevention hasn't been kind of universal. It hasn't been worldwide. A lot of different cultures, especially in our culture, is you don't go until it hurts. And it's kind of an uphill battle to really drive home the message of before it hurts is when you need to go.

So spending the time to be able to be chairside, and speak to the patient face to face, and allowing them to see that preventative coming in for your checkups, coming in for your cleanings, even though nothing bothers them, even though nothing's hurting, is just a lot more important than, coming in only for spot treatments, limited treatments, and the message that they've received for, you know, maybe the first 60 years of their life versus the message that they're receiving now. It is kind of that development of trust between the dentist and the patient, to understand why are we recommending these treatments?

Why are we recommending at home that you're doing all the preventative care. Just allowing them to understand the benefits of it and making sure that you're keeping up with that message across the board.

Host: And so the message is, don't wait until it hurts, right?

Annie Kwan, DDS: Yes, please.

Host: Please.

Annie Kwan, DDS: Yes.

Host: We'll include the please as well.

Annie Kwan, DDS: Yes. It is definitely, it is definitely much easier, as far as just preventative treatment versus, if you're having to do a cavity or root canal or extractions, those tend to weigh heavily on, especially the older population as they have more issues, being able to have one less thing that they need to be concerned with.

Host: No question about that. Many have learned the hard way, unfortunately. Folks, we trust you're now more familiar with geriatric dentistry. Dr. Annie Kwan, valuable information indeed for all ages. Thanks so much again.

And for more information, please visit ichs.com. Now, if you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. Thanks again for being part of Together We Rise from International Community Health Services.